From the perspective of the development of military medicine, the Russo-Japanese War was one of the most important wars in history. Both Japan and Russia developed and introduced major medical innovations to treat battle casualties and disease that set new standards for the armies of the world. Improving greatly upon the American and German models, the Japanese were the first to introduce a thoroughly modern military medical system that integrated all the major elements of casualty care and disease prevention into a complete command structure. The Japanese Army was the first to require a medical plan as part of the combat operations order, the first to place the chief of medical services in the general staff structure, the first to provide full rank and status to medical corps officers in combat theaters of operations, and the first to create an effective, independent medical supply service with its own transport. These organizational changes constituted major modifications to the medical corps and revolutionized its capability to attend to its mission.
Building on the German Army’s initial efforts in 1870, the Japanese Army became the first modern army to thoroughly integrate modern science into the care and treatment of casualties. Its emphasis on disease and infection prevention by applying the lessons of bacteriology, vaccination, and antiseptic surgery resulted in an army losing fewer casualties to disease and infection than to enemy weaponry for the first time in two hundred years. The army’s hygienic practices and field discipline far surpassed anything that modern history had ever seen, and it resulted in a level of manpower conservation that remained unsurpassed until the Vietnam War.
Given the generally backward state of Russian medicine and the almost pre-modern condition of the Russian military administrative structure, that the Russians made such major advances in the treatment of psychiatric casualties is surprising. It is no exaggeration to say that the Russian Army established the modern foundations of military psychiatry both organizationally and clinically. The conceptual foundations of modern military psychiatry remain unchanged in their essentials since the Russian Army introduced them in 1905. The principles of proximity, immediacy, and expectancy, known in the modern discipline by the acronym PIE, still undergird all methods of battlefield treatment of psychiatric casualties. While the discipline has since expanded the range of diagnostic categories, the original categories of mental disorder found on the battlefield remain as sound today as they were when the Russians first identified them more than a century ago.
When taken together, then, the Russo-Japanese War was a period of major innovation in military medicine. It was a time when modern military somatic and psychiatric medicine made its debut.
WORLD WAR I
The First World War was the most destructive conflict in history up to that time: the combatants mobilized 60 million men, killed 7 million of them, and wounded more than 19 million. Half a million soldiers underwent amputations. The introduction of smokeless powder propelled rifle and artillery projectiles at higher velocities and greater distances than ever before. Shrapnel and exploding artillery shot caused 70 percent of battle wounds and produced mutilations on an unprecedented scale.66
Military medicine witnessed a number of important medical advances in treating the wounded. For the first time diagnostic bacteriology conducted in mobile laboratories was available in frontline hospitals. Improvements to X-ray machines, making them lighter, allowed their use in forward surgical stations. Intravenous saline infusions in resuscitation became common, as did clinical thermometers, hemostatic forceps, hypodermic syringes, and better retractors and surgical lighting. The first field blood transfusion teams were introduced, and the casualty clearing station grew into the evacuation hospital and became a standard feature of the casualty evacuation system.
At the start of the war, the doctrine of conservative treatment and healing by secondary intention was widely used with disastrous results. The continued practice of limited debridement and secondary closure of severe shrapnel wounds that were contaminated by the richly manured soil of the battlefield led to high rates of amputation and infection, the latter almost always in the form of deadly gas gangrene. Wound mortality approached 28 percent in 1915, and the amputation rate ran as high as 40 percent for wounds of the extremities involving injuries to the bone.67 First attempts to control infection involved using various antiseptics directly on the wound. Experience taught that this procedure was ineffective and often harmed healthy tissue. Military surgeons gradually relearned old lessons and used debridement on all major wounds. In addition, they continually irrigated wounds with Eusol (Edinburgh University Solution of Lime) and, eventually, Carrel-Dakin solution—a diluted antiseptic of sodium hypochlorite and boric acid—to aid draining. Mobile bacteriology laboratories attached to the various hospitals took daily bacterial smears to determine the bacteria count before doctors closed wounds and saved many lives.
As these surgical procedures were gradually implemented, the rate of wound infection fell dramatically. In 1917, the Battles of Messines and Passchendaele (also known as the Third Battle of Ypres) produced more than twenty-five thousand wounded, of which only eighty-four contracted gas gangrene.68 By the end of the war, wound suppuration had become relatively rare. Signs in hospitals often included a statement by Alexis Carrel (1873–1944), the coinventor of the Carrel-Dakin solution: “Every wounded man who develops suppuration has the right to ask his surgeon to justify it.” By war’s end, overall wound mortality was 8 percent compared to 13.3 percent for the American Civil War and 20 percent in the Crimean War.69
Advances in wound surgery and reduced infection had the effect of decreasing the amputation rate, and as surgeons abandoned the traditional practice of prophylactic amputation for all compound fractures by 1917, the amputation rate dropped to less than 10 percent. Nonetheless, with half a million total amputations during the war, this area of surgery generated considerable interest and led to standardized surgical procedures, clinical definitions, prosthetic limb application, and the start of the science of rehabilitation. Sir Robert Jones (1857–1933), inspector of military orthopedics for the British Army, is credited with establishing seventeen rehabilitation centers of various types and introducing the first comprehensive approach to the rehabilitation of combat wounded attempted by an army.70 More than four hundred surgeons gained training in the new science of orthopedics during the war.71 Jones also advocated using the Thomas splint at all first aid posts when transporting men with compound femur fractures, reducing the mortality rate from this injury to less than 20 percent.72
Attempts to control shock in treating the wounded received major attention. Surgeons were aware that low blood pressure triggered shock, and they first tried intravenous saline replacements after the Battle of the Somme in 1916 but had disappointing results. In the same year, forward area surgeons tried to conduct blood transfusion by the direct method. Dr. J. Roussel is credited with making the first successful battlefield blood transfusion during the Franco-Prussian War. He drew upon the work of James Aveling, who invented a rubber bulb syringe to pump blood more quickly from the donor to the recipient. The French, Austrian, Belgian, and Russian armies adopted Roussel’s “transfuseur” apparatus at the turn of the century.73
Blood transfusions were not common before World War I, but sufficient numbers were performed for researchers to determine its major problems. The donor’s blood tended to clot before it could be infused into the recipient’s system. Various anticoagulants, such as sodium phosphate, were first used as early as 1869. Attempts were also made to remove the blood’s fibrin, but this process had the undesirable effect of removing other valuable components. The introduction of the Kimpton-Brown waxed tubes in 1917 to reduce clotting in the transfer apparatus helped only slightly.74 Antiseptic control of bacteria helped reduce the danger of infection, and in 1909 Karl Landsteiner (1868–1943), working from his discovery of blood groups, developed a classification of blood types to reduce the probability of reactions from transfusion.
By the start of World War I, Alber
t Hustin (1882–1967) had shown that sodium citrate was an effective anticoagulant; thus, for the first time, it became possible to store blood for future use. Coupled with type matching and waxed transfer tubes, these advances made blood transfusions practical. Although transfusion remained a major procedure that was as complex as the surgery itself, the British and American armies established the first transfusion resuscitation teams and assigned them to special shock centers. These teams could be moved quickly in anticipation of major casualties and often deployed forward to the field hospitals. The war ended before transfusion could be applied on a large scale, but the value of field transfusion units was clearly established. During the interwar period, practically every major medical service established these teams for use in the next war.
Trench warfare produced large numbers of facial wounds, and more than three thousand of the eight thousand Allied personnel who suffered facial wounds died.75 At the beginning of the war, no trained surgeons had specialized in treating maxillofacial injuries and no books on the subject of general plastic surgery were available.76 Military surgeons were so inexperienced in this area that they often transported their patients who had facial injuries in the supine position, one that blocked their airways and killed them. The British government’s initial effort to help those suffering from maxillofacial injuries was to contract civilian artists to create and paint realistic masks that the disfigured could use to hide their injuries.77 In time, however, the British established special hospitals to treat these casualties, and significant numbers of plastic surgeons were trained to staff them. The British started the first maxillofacial injury hospitals, but the Americans’ entry into the war in 1917 stimulated greater interest. By June 1917, the Americans had established four hospitals to handle maxillofacial injuries and are generally credited with introducing the team approach to reconstructive surgery that became standard in World War II.
Although military medicine had made great strides in disease treatment, the richly manured soil of Flanders caused high rates of tetanus infection in the early years of the war. Advances in tetanus antitoxin vaccines produced a more effective vaccine that saw its first large-scale military use during the war. Tetanus had a mortality rate of 89–95 percent in the Civil War, and shortly before World War I when the first anti-tetanus vaccines were available, the mortality rate was still between 40 and 80 percent.78 In 1914, 32 percent of British wounded contracted tetanus. With the introduction of new vaccines and the practice of giving a wounded man a tetanus shot as soon as possible, the rate of tetanus infection dropped to 0.1 percent by war’s end.79 Even so, the mortality rate of those who contracted tetanus remained between 20 and 50 percent. Advances in tetanus antitoxins, the introduction of regular inoculations in the interwar period, and the widespread practice of debridement and secondary closure of wounds reduced tetanus deaths to almost zero by the end of the war. Among U.S. forces in World War II, of the 10.7 million men who served, only eleven known cases of tetanus were recorded.80
Advances in disease prevention and treatment were evident in World War I’s low rates of death to enteric fever, plague, smallpox, cholera, and typhus. New typhoid vaccines drastically reduced typhoid rates. In the Spanish-American War, 20 percent of the soldiers contracted typhoid, but typhoid afflicted only 0.04 percent of the American Army in World War I.81 While scientists had made some advances in the treatment of dysentery and malaria, these two diseases remained major problems. Trench foot (emersion foot) disabled thousands of soldiers on both sides, and trench fever, caused by parasites in the fecal matter of the louse, produced more than 200,000 casualties on the Allied side.82 Allied troops suffered 115,361 casualties to frostbite during the war. For the most part, however, establishing professional military medical services in the major armies paid big dividends as medical officers used their expertise in disease control and prevention. Except for the worldwide influenza epidemic of 1918, disease claimed far fewer men in World War I than had been the case in other wars.
Germany
The German Army was the most medically prepared of all the combatants of the First World War. The organizational model of its field medical care that had been unveiled in the Franco-Prussian war—complete with its first aid kits, forward surgery, casualty clearing stations and transport system, the integration of rear area hospitals into a complete system linked by rail, and the first large-scale introduction of Listerian methods of antiseptic and aseptic surgery—remained in place in 1914. The Germans’ penchant for planning—a product of that other German invention, the general staff—meant that sufficient medical personnel, supplies, rolling stock, and plans for moving the wounded had been put in place ten years before the war.83 Furthermore, Germany was the only nation that had established plans and facilities for rehabilitating the wounded and disabled.
After 1870, German medicine became totally integrated into the larger scientific community. Accordingly, German military medicine was able to muster the full range of scientific and technical expertise drawn from the intellectual resources of the entire nation. On the eve of the First World War most other nations had not fostered this degree of integration; however, by war’s end, the German pattern was characteristic of all the major combatants’ military medical establishments. Meanwhile, German casualties amounted to 1,531,048 killed in action, and of a total number of 19,461,265 men admitted to the hospital for all causes, 155,013 died from disease. The total mortality of the German Army was 1,686,061, or a wound mortality of approximately 8.6 percent.84
Russia
Of all the major combatants, the Russian Army, whose general health and social condition had begun to collapse even before the war, endured the worst medical situation. The available statistics of Russian losses indicate that their disease rate was the highest of all combatants. A total number of 5,069,000 are recorded as having been hospitalized for disease. Of these cases, 21,093 had contracted typhus, 97,522 typhoid, 75,429 remittent typhoid fever, 64,364 dysentery, 30,810 cholera, 2,708 smallpox, and 362,756 scurvy.85 A German medical team sent to Russia in July 1916 reported that every division set aside a hundred beds at the corps hospital to care for the victims of scurvy.86 The state of Russian preventive field medicine was terrible, and its troops suffered huge losses from diseases that had ceased to be serious medical problems in other armies. The official Russian figure of only 130,000 soldiers dead from disease, therefore, is probably not reliable.
Based on the only recognized statistical study, Russian forces lost 664,890 men killed in action with 18,378 dead from wounds within their units; that is, medical personnel never reached them for evacuation. An additional 300,000 soldiers died in hospital from their wounds. The Russians suffered a total of 3,748,000 men wounded, suggesting a mortality rate of approximately 8 percent.87 Another 1.4 million disabled men were discharged into a society wracked by revolution and lacking all facilities for rehabilitation.
France
The French medical service remained the only example of a major army whose medical officers were not part of an independent medical service and were under the command of line officers. Moreover, the general staff’s attitude regarding field hygiene had not changed since the last century. The men had little interest in hygiene and provided no training; responsibility for hygiene remained with unit commanders, unimpeded by the medical service. As a result the French Army suffered 50,000 cases of typhoid in the first three years of the war. When American units were assigned to former French training areas, they were horrified to find that almost all the water supplies were polluted by typhoid.88
Without an independent medical supply service, the French medical officers had to secure the quartermaster’s written permission for all supplies and vehicles. The chief surgeon of the army was relegated to the second line staff and separated from the general staff by thirty miles, indicating that the army had made no attempt to integrate a medical plan into the overall battle plan. Consequently, units often moved away from their hospitals and medical support withou
t the hospitals being made aware of the redeployment.89
The French Army attempted to mobilize its civilian reserve physicians and surgeons for war only to discover that it possessed no complete list of their names and addresses. More than half of the medical personnel mobilized declined to serve as officers, resulting in a great waste of trained medical talent.90 The number of physicians and surgeons that the general staff had originally estimated as required for war turned out to be quite insufficient. Indeed, the army needed more than double the planned number of medical assets to handle the high casualty rates.
The organizational structure remained a shambles throughout the war. The chief surgeon had only a small staff to support an army operating over a thirty-five-mile front that was a hundred miles deep. At the beginning of the war, the chief surgeon did not have his own transport. The general staff first echelon had to approve any requests for personnel, equipment, reinforcements, and even the deployment of medical resources to field units first, making coordination with events on the battlefield an impossibility. The French began the war short of medical equipment. Its table of organization strength for medical assets, which had been drawn in 1910, remained unchanged. Only ten army corps had sufficient surgical material to supply their field ambulances, and the hospital trains were more like boxcars than trains suitable for casualties.91 Because these trains were not under the medical officers’ control, trains were not only underutilized but also faced incessant delays and overcrowding at assembly points.
Troops assigned to medical detachments still reported to their line officers and not to the medical officers. Detachments of wagon drivers and litter bearers were under the orders of the logistics and transport officers and not the chief surgeon of the hospital. No medical officer, including the director of the medical service, could order a change in the disposition of medical personnel without the army corps commander’s approval.92 The medical officer was even forbidden to send troops to the forward dressing stations to relieve them during an influx of heavy casualties. The service’s inability to move medical assets to the areas with the greatest casualties and lack of reliable manpower for the ambulance service produced delays in reaching and evacuating the wounded. Although the medical officers finally obtained some control over their own personnel by 1915, the problem of directing personnel assets persisted until the end of the war.
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